Intake - Child FIRST

Wimmera Child FIRST Community based referral form

Office Use Only
IRIS
Client Code
Case No
Referral Assessed As / Significant Wellbeing Concerns
(See definition below) / q
Referral Assessed As / General Family / q

Please ensure all fields marked with * are completed to enable a more thorough assessment and referral process.

REFERRER DETAILS
*Name of Referrer:
*Address:
*Agency
*Phone:
*Mobile:
*Email:
*Has the Referral been discussed with the Family?
*Has Family given consent to referrer to contact Child FIRST?
(Please indicate if it was verbal or written?)
*Does the referrer have a significant concern for the wellbeing of the child/ren?
(See definition across in box) / Yes ¨ No ¨
“Serious presenting problems that impact upon a child’s care and development and where the parent is unwilling or unable to access appropriate supports to make positive changes”.
In order to establish “Significant Concerns about a child’s wellbeing these two conditions are required:
1.  The problem serious and impacts on a child’s care and development.
2.  The parent is unwilling or unable to access appropriate supports to make positive changes (This may include that a parent does access service, but does not make sufficient change to improve the child’s care and development.
*Does referrer want their identity to be protected? / Yes q No ¨
The Children, Youth and Families Act 2005, allows for the identity of a referrer to Child FIRST to be protected from being known to the family. In order to engage families we prefer to be open with them, and being that engagement with the service is voluntary we encourage, where possible for referrers to discuss the referral with the family.
OFFICE USE ONLY
CHILD FIRST INTAKE TO COMPLETE
Date referral received by Child FIRST
Person receiving referral
Case Priority / Low / Medium / High
*Has SCPPCB or CP Intake been Consulted?
(NB: Common consultation record must be recorded in IRIS under “consultation” heading in case notes)
If yes, supply date of consult:
PARENT DETAILS (Details relating to Parent/Carer/Guardian/Primary Caregiver)
The person the service will have the most contact with
*Name:
*Date of Birth:
*Relationship to children
*Gender:
*Address:
(include Post code)
*Phone:
*Mobile:
*Language at home: / *Interpreter Required: Y/N
*Source of Income / No Income q / Centrelink benefits
¨ / P/T
Employed
q / F/T
Employed
q / Other: (please specify)
*Housing Tenure: / Renting: Public
q / Renting: Private
q / Transitional
Housing q / Mortgage
¨ / Other: (please specify)
*Relationship Status / Single
q / Married/
Partner
q / Separated/
Divorced
q / Widowed
q / Other: (please specify)
*Culture Identity / Indigenous
q / TSI
q / CALD q / Other (please specify):
Other Significant Family Members/People
*Name: / M/F / D.O.B / Relationship to Children / Residing with Client / Contact Details
CHILDREN IN HOUSEHOLD AND/OR FAMILY UNIT (Enter in ‘Related Persons’ IRIS)
*Name: / *DOB: / *Gender / *Residing with Client (Yes/No) / *Relationship to Client / *Cultural identity
CHILD PROTECTION INVOLVEMENT
*Any Past Protective Services Involvement?
*Are Protective Services involved currently?
*Is a Notification to Child Protection Required?
*Include ALERTS (including any worker safety issues if known, dangerous behaviour, violence etc.)
Alerts (including worker safety issues) / Yes / No / Unknown / Details
Weapons in the home / ¨ / ¨ / ¨
Violence towards workers / ¨ / ¨ / ¨
Dangerous Pets at the home / ¨ / ¨ / ¨
Other: (explain)
COMMUNITY PARTNERSHIPS, RESOURCES & NETWORKS
(including Networks, engaged neighbours, families social integration, education, health, welfare, police, church group, cultural group etc.)
*Agency / *Contact Person / *Phone/Contact Details / *What role is played by this person?
*Who in the family do they provide service to?
ISSUES IDENTIFIED BY THE REFERRER
(What are you/family concerned about?)
(What do you/family think they need?)
(Is basic care being provided? Do the children require protection from harm? Describe the parent/carer capability. Describe the connection to the primary caregiver, describe the connection between family and siblings. Describe the connection the family has with school, childcare, friends, community and culture. Describe the children’s health, physical development, emotional and behavioural development)
Please forward completed Referral Form to Wimmera Child FIRST
either by fax, email or post (email preferred)
Wimmera Child FIRST
Fax: (03)5382 1566
Email:
Post: C/O Wimmera Child FIRST
Wimmera Uniting Care
PO Box 442
Horsham 3402
Contact Details
Office Phone: (03) 53624000 Intake Phone: 1800 195 114

FS14/01

Last Reviewed Date: May 2015 Uncontrolled copy when printed Page 2 of 4